Coventry Operations Ri Llc Dba Respiratory And Reh

F 0678

serious injury, harm, impairment, or death for Resident ID #3, who was pronounced dead minutes after arriving to the hospital.Cross reference F 726

Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Coventry Operations RI LLC Dba Respiratory and Reh

10 Woodland Drive Coventry, RI 02816

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or potential for actual harm

Based on record review and staff interview, it has been determined that the facility failed to ensure that services provided by the facility meet professional standards of quality relative to following physician's orders for 1 of 3 residents reviewed for a physician referral for an appointment, Resident ID #5.Findings are as follows:According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states, The physician is responsible for directing medical treatment, Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients.Record review revealed that the resident was admitted to the facility in August of 2022 with diagnoses including, but not limited to, hemiplegia and hemiparesis following cerebral infarction (weakness and paralysis of one side of the body following a stroke), dependence on ventilator, use of tracheostomy (a surgically created opening in the windpipe to assist with breathing) and gastrostomy (a surgical opening into the stomach for purposes of feeding).Review of a progress noted dated 8/3/2025 revealed that the resident sustained a witnessed fall while a Nursing Assistant (NA) was changing his/her brief and landed on his/her bilateral knees.

Additionally, the note revealed that the resident complained of 10 out of 10 pain and was to have x-rays of

the affected area.Review of a, Radiology Results Report dated 8/4/2025 states in part, .Findings.there is a fracture of the distal tibia and fibula.Review of a progress note dated 8/4/2025 states in part, Resident returned from hospital with report of: [Resident ID #5] has a left ankle fracture. We placed in a splint. [S/he] will need to follow up with outpatient orthopedics/podiatry in 1 week.Review of a progress note dated 8/12/2025 authored by Physician Assistant (PA), Staff M, states in part, .Nursing staff understands that patient should have orthopedic follow-up.Review of a progress note dated 9/4/2025 authored by Staff M, states in part, Nursing staff instructed to reach out to orthopedic and offer virtual visits with me in attendance to help them. They are established at then send x-ray results to orthopedic.Review of a progress note dated 9/22/2025 authored by Physician, Staff N, states in part, .outpatient orthopedic follow-up.Record review failed to reveal evidence that Resident ID #5 had an Orthopedic follow up as ordered.During a surveyor interview on 10/27/2025 at 2:33 PM with transport aide, Staff O, she revealed that she made an appointment for Resident ID #5 with an orthopedic clinic however, the office cancelled the appointment. Additionally, Staff O revealed that she spoke with PA, Staff M, about the cancelled appointment and believed that he was going to be scheduling an appointment for Resident ID #5.During a surveyor interview on 10/28/2025 at 9:11 AM with Staff M, in the presence of the Administrator he revealed that he does not schedule resident appointments and did not schedule an orthopedic appointment for Resident ID #5. Additionally, he revealed he would expect the staff at the facility to follow orders including making appointments.

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Coventry Operations RI LLC Dba Respiratory and Reh

10 Woodland Drive Coventry, RI 02816

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

record review and staff interview, it has been determined that the facility failed to ensure that the resident environment remains as free of accident hazards relative to falls for 1 of 3 residents reviewed, Resident ID #5. The facility failed to implement the resident's care plan, leading directly to an accident and injury to resident #5, who sustained a left distal tibia (large shinbone) and fibula (smaller shinbone) fracture.Findings are as follows:Review of a community reported complaint received by the Rhode Island Department of Health on 10/24/2025 alleges that Resident ID #5 sustained 2 falls and did not get the appropriate care related to his/her injuries.Record review revealed that the resident was admitted to the facility in August of 2022 with diagnoses including, but not limited to, hemiplegia and hemiparesis following cerebral infarction (weakness and paralysis of one side of the body following a stroke), dependence on ventilator, use of tracheostomy (a surgically created opening in the windpipe to assist with breathing) and gastrostomy (a surgical opening into the stomach for purposes of feeding).Review of a care plan last updated on 7/29/2025 revealed an intervention that states, [Resident ID #5] requires assist of 2 for bathing, dressing, grooming, incontinent care.Review of an Annual Minimum Data Set assessment dated [DATE REDACTED] revealed that the resident is totally dependent on staff for all activities of daily living including, turning from side to side, toileting, and transfers.Review of a progress noted dated 8/3/2025 revealed that the resident sustained a witnessed fall while a Nursing Assistant (NA) was changing his/her brief and landed on his/her bilateral knees. Additionally, the note revealed that the resident complained of 10 out of 10 pain and was to have x-rays of the affected area.Review of a, Radiology Results Report dated 8/4/2025 states in part, .Findings.there is a fracture of the distal tibia and fibulal fracture.Review of a facility provided statement authored by NA, Staff L, revealed that she was providing incontinence care to Resident ID #5 alone when s/he rolled out of bed and onto the floor.An interview was attempted with Staff L with no return call. During

a surveyor interview on 10/28/2025 at approximately 12:00 PM with the Director of Nursing Services in the presence of the Administrator he was unable to provide evidence that the staff followed the care plan relative to utilizing 2 staff members for incontinence care.As the facility failed to follow the care plan with regards to utilizing two staff members for incontinence care, this resident was rolled off of the side of the bed and sustained a left distal tibia and fibula fracture. This failure by the facility to ensure that staff consistently implemented resident-specific interventions outlined in the care plan, thereby not providing care in accordance with accepted standards and the resident's assessed needs.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Coventry Operations RI LLC Dba Respiratory and Reh

10 Woodland Drive Coventry, RI 02816

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0710

Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

record review and staff interview, it has been determined that the facility failed to ensure that the resident's physician completed a medication reconciliation upon readmission. This failure resulted resulted in a resident receiving the medication Metolazone (a medication prescribed to treat fluid retention) in error, Resident ID #1.Findings are as follows:Record review of a facility reported incident submitted to the Rhode Island Department of Health on [DATE REDACTED] revealed that Resident ID #1 had experienced a fall on [DATE REDACTED] and was transferred to an acute care hospital. Additionally, the resident subsequently died.Record review revealed Resident ID #1 was readmitted to the facility in October of 2025 with a diagnosis including, but not limited to, heart failure, pulmonary hypertension (a condition where the blood pressure in the arteries of the lung is high), and chronic kidney disease.Review of the progress notes revealed the resident was transferred to an acute care hospital and was admitted for congestive heart failure, exacerbation, and respiratory distress on [DATE REDACTED] and was later readmitted to the facility on [DATE REDACTED].Review of a hospital document titled, Continuity of care adult discharge dated [DATE REDACTED], revealed that the resident was readmitted with an order for Metolazone 5 milligrams (mg) by mouth, three times a week.Review of a physician's order dated [DATE REDACTED], entered by Registered Nurse, Staff A, revealed the order for Metolazone 5 mg was incorrectly transcribed into the record to be given three times daily instead of three times a week.Review of

a progress note authored by the Resident ID #1's physician dated [DATE REDACTED] revealed that he saw the resident that day at approximately 5:00 PM following his/her readmission to the facility. Additionally, he indicated that s/he was started on Metolazone 5 mg, three times a week.Record review failed to reveal evidence that Resident ID #1's physician identified the Metolazone order transcription error upon seeing the resident and reviewing his/her medical record.During a surveyor interview on [DATE REDACTED] at 11:03 AM with the resident's physician, he revealed that he had seen the resident at approximately 5:00 PM on [DATE REDACTED], the day after his/her readmission. Additionally, he indicated that he reviewed the resident's medical record but failed to identify the Metolazone transcription error. He further revealed that he does not reconcile the medication orders in the facility's system with the hospital continuity of care form because it is not feasible. Further, he revealed that it is the nursing staff's responsibility and that is why they have a medication verification checklist in place.During a surveyor interview [DATE REDACTED] at approximately 10:32 AM with the Director of Nursing Services, he revealed that it is his expectation that the provider would reconcile the resident's medical record with the hospital continuity of care documents to ensure accuracy.Cross reference F 726 and F 760

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Coventry Operations RI LLC Dba Respiratory and Reh

10 Woodland Drive Coventry, RI 02816

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

working schedule for the 3:00 PM to 11:00 PM shift on 9/29/2025 revealed, only two nurses and three NAs worked on the unit, and not the 5/4 NA's as stated in the Staffing Guidelines.During a surveyor interview on 10/28/2025 at approximately 1:55 PM, with the Administrator and Director of Nursing Services, they indicated that they were aware there were only 3 NAs scheduled to work on the unit. Additionally, they could not provide evidence that they followed their staffing guidelines and/or adjusted the staffing assignments based on patient volume/density and acuity of the unit. Furthermore, they acknowledged that Residents ID #5 had an unwitnessed fall from bed on 9/29/2025 where s/he fractured his/her nasal bone and at the time of the fall the unit was staffed with 3 NA's instead of the 5/4 NA's, as stated in the staffing guidelines.The facility failed to ensure that sufficient staffing levels were maintained in accordance with the facility's own staffing guidelines and resident acuity needs. As a result, Resident ID #5, who is fully dependent on staff for care, experienced an unwitnessed fall resulting in a nasal fracture. This demonstrates a failure by the facility to provide adequate supervision and to ensure the health and safety of residents through the consistent implementation of appropriate staffing levels and care practices.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Coventry Operations RI LLC Dba Respiratory and Reh

10 Woodland Drive Coventry, RI 02816

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

his/her condition was noted to be worsening. He was unable to provide evidence that the facility maintained competent nursing staff with the appropriate skills set to properly care for Resident ID #1 following a traumatic fall.The facility's failure to ensure that they maintain sufficient nursing staff with the appropriate skill sets to provide nursing and related services to assure resident safety relative to the medication verification process, resident assessment during an emergency situation, and providing effective CPR consistent with basic life support protocols, had the potential to cause serious injury, harm, impairment, or death for Resident ID #1 and #3, who both subsequently died.Cross reference F 678 and F 760

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Coventry Operations RI LLC Dba Respiratory and Reh

10 Woodland Drive Coventry, RI 02816

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

blood vessels) to the forehead, swelling around both eyes, and significant bleeding of the mouth and nose that had visible clots. More importantly, the resident was found to not be breathing, and EMS inserted an artificial airway device and began providing rescue breaths via an Ambu bag (resuscitation bag).During a surveyor interview on [DATE REDACTED] at 12:00 PM with Licensed Practical Nurse, Staff F, she revealed that she identified the medication error regarding the resident's Metolazone and notified a provider, prior to the resident's unwitnessed fall. She further revealed that the provider had ordered blood work, a blood pressure reading to be obtained, and an ultrasound of the heart. Additionally, she revealed that the resident appeared more sleepy.During a surveyor interview on [DATE REDACTED] at approximately 2:25 PM with Respiratory Therapist, Staff J, she revealed that she entered the resident's room after she witnessed staff rushing in to find the resident face down on the floor in a pool of blood. She further revealed that the resident receives continuous oxygen via a nasal cannula (oxygen tubing), and that the resident must have fallen so forcefully,

it caused the oxygen tubing to snap and break. Additionally, she revealed that the resident must have fallen as soon as s/he stood up based on how s/he was found on the floor.During a surveyor interview on [DATE REDACTED] at 1:58 PM with RN, Staff A, she acknowledged that she was the nurse that incorrectly transcribed the Metolazone order that was entered on [DATE REDACTED] to be given three times a day instead of three times a week.

Additionally, Staff A acknowledged that the hospital paperwork indicated to administer Metolazone 5 mg three times a week and revealed that the provider had approved that order.During a surveyor interview on [DATE REDACTED] at 1:15 PM with the Director of Nursing Services, he acknowledged that the resident's Metolazone 5 mg order was incorrectly transcribed resulting in the resident receiving the medication three times on 10/10 and 10/11, and once on [DATE REDACTED] when s/he should have received the Metolazone 5 mg three times a week.

He was unable to provide evidence that the facility ensured that residents are free of any significant medication errors.During a surveyor interview on [DATE REDACTED] at 12:33 PM with a Registered Pharmacist, she revealed that Metolazone 5 mg three times a week is a typical prescribed dose and frequency. Additionally,

she revealed that adverse/side effects of Metolazone use has the potential to increase the diuretic effect that could result in dehydration, as well as lethargy, dizziness, orthostatic hypotension, fainting, and syncopal episodes.The facility's failure to ensure that residents are free of any significant medication errors had the potential to cause serious injury, harm, impairment, or death for Resident ID #1, who subsequently died at the hospital.Cross reference F 726

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Coventry Operations RI LLC Dba Respiratory and Reh

10 Woodland Drive Coventry, RI 02816

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Based on record review and staff interview, it has been determined that the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations (including nights and weekends) and emergencies. The facility must also review and update this assessment whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment.Findings are as follows:Review of a community reported complaint received by the Rhode Island Department of Health on 10/24/2025 alleges that Resident ID #5 sustained 2 falls and did not get the appropriate care related to his/her injuries.

Additionally, the complaint alleges that the facility does not have enough staff or qualified staff.Review of a document titled, Facility Assessment dated March 2025-2026 states in part, .Acuity-Sufficiency Analysis Summary.4. Please document total #[number]/average/range of staff required to ensure sufficient number of qualified staff are available to meet each resident's needs: Kindly reference the attached Staffing and Personnel Worksheet in the Attachments section of this Facility Assessment.Further review of the Facility Assessment revealed multiple sections for supporting documentation that state, no records were found.

Additionally, there was not a Staffing and Personnel Worksheet completed in the facility assessment.Additional review of the Facility Assessment revealed a previous employee listed as the Administrator and not the current Administrator.During a surveyor interview on 10/28/2025 at 12:25 PM with

the Administrator he acknowledged that the Facility Assessment is not complete and does not accurately reflect the staffing patterns of the facility or have the current Administrator listed.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Coventry Operations RI LLC Dba Respiratory and Reh

10 Woodland Drive Coventry, RI 02816

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Based on record review and staff interview, it has been determined that the facility failed to ensure that resident's records are complete and accurately documented, relative to 1 of 1 resident reviewed who received Metolazone (medication to treat fluid retention) inaccurately, Resident ID #1. Findings are as follows:Record review of a facility reported incident submitted to the Rhode Island Department of Health on 10/14/2025 revealed that Resident ID #1 had experienced a fall and was transferred to an acute care hospital to be treated. However, the facility was later informed that the resident had passed away.Record

review revealed the resident was readmitted to the facility in October of 2025 with diagnoses, including but not limited to, heart failure (a condition in which the heart muscle cannot pump blood effectively), pulmonary hypertension (a condition where the blood pressure in the arteries of the lung is high) and chronic kidney disease.Record review of a hospital document titled Continuity of Care Adult Discharge dated 10/9/2025 revealed that the resident was discharged with a list of medications which include, but is not limited to, Metolazone 5 milligrams by mouth three times a week for 30 days.Record review of a physician's order dated 10/9/2025, entered into the electronic medical record by Registered Nurse, Staff A, revealed Metolazone 5 milligrams by mouth three times a day instead of three times a week, as ordered.Record review of the October 2025 Medication Administration Record revealed the resident had received 7 doses of the above-mentioned medication in 3 days instead of 2 doses, as ordered. During a surveyor interview on 10/15/2025 at 1:15 PM with the Director of Nursing Services, he acknowledged that

the resident's Metolazone 5 mg order was incorrectly transcribed resulting in the resident receiving the medication three times on 10/10 and 10/11, and once on 10/12/2025 when s/he should have received the Metolazone 5 mg three times a week.

Event ID:

Facility ID:

If continuation sheet